Re: Breast-cancer patient gets radiation overdose

["Sandy Perle" <sandyfl@earthlink.net>]

> Two errors allowed the overdose, Laramore said. A technician incorrectly
> entered the prescribed radiation dose into the linear accelerator's
> computer. Then a medical physicist failed to catch the error during any of
> four weekly medical record checks.
> 
> The system of weekly record checks was instituted after the accident
> involving the boy occurred in 1994. Laramore said the physicist is still
> employed at the UW while the department of radiation oncology investigates
> the accident.

The above points out that while a positive countermeasure was 
implemented in 1994, there was apparently no continual follow-up, 
ensuring that the countermeasure was effectively implemented. The 
fact that this second incident occurred after a period of 4 years no 
way implies that whatever was instituted originally, was as far 
reaching as necessary. The fact that the medical physicist failed to 
determine there was an error, according to the article, and a 
significant error considering that the setting was twice the 
prescribed application, borders on negligence. The investigation will 
identify many root causes, for sure. It will be interesting to 
determine whether or not the physicist was actually performing the 
verification, or having a subordinate perform the reviews, and simply 
signing the forms, as if he/she had performed it. In any event, the 
previous item is just one item of speculation at this point. 

Verification of computer entries is an essential part of the 
business, considering the doses being given to these patients. If 
they are not performing a double verification, they should have. How 
one can miss the errors, four weeks in a row, is a mystery to me, 
unless the above occurred, or, the checks were never made in the 
first place, and the form falsely documented. This speculative 
cause is quite possible, after an individual becomes complacent, 
"knowing" that everything is OK, since it's been that way for the 
past4 or 5 years.

Complacency and not taking control is a serious issue, and news 
items like this make it even more difficult on an already shrinking 
nuclear option and public scrutiny of our "world".

------------------------
Sandy Perle
E-Mail: sandyfl@earthlink.net
Personal Website: http://www.geocities.com/capecanaveral/1205

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